What is the presenting history of present illness (HPI) for a patient with suspected adrenal insufficiency (Addison's disease)?

From the Guidelines

A comprehensive HPI template for suspected adrenal insufficiency should include the patient's presenting symptoms, particularly unexplained collapse, hypotension, vomiting, diarrhea, hyperpigmentation, hyponatremia, hyperkalemia, acidosis, and hypoglycemia, as these increase clinical suspicion of primary adrenal insufficiency (PAI) 1.

Key Elements of HPI Template

• Presenting symptoms:
  • Classic manifestations such as fatigue, weakness, weight loss, anorexia, nausea, vomiting, abdominal pain, salt craving, and postural dizziness
  • Onset, duration, and progression of these symptoms
• Precipitating factors:
  • Recent illness, surgery, trauma, or stress that may have triggered or exacerbated symptoms
  • Recent glucocorticoid use (including topical, inhaled, or injected forms) and any abrupt discontinuation
  • Medications that can affect the hypothalamic-pituitary-adrenal axis like ketoconazole, etomidate, or opioids
• Relevant medical history:
  • Autoimmune disorders (thyroiditis, type 1 diabetes, vitiligo, pernicious anemia) which may suggest autoimmune adrenalitis
  • Family history of autoimmune disorders or adrenal insufficiency
  • History of tuberculosis, fungal infections, or HIV which can affect the adrenal glands
• Physical findings:
  • Hyperpigmentation (particularly in skin creases, mucous membranes)
  • Hypotension, orthostatic changes, and vitiligo
• Laboratory results:
  • Electrolyte abnormalities (hyponatremia, hyperkalemia)
  • Hypoglycemia or eosinophilia

Diagnostic Considerations

According to the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1, the diagnosis of PAI should be considered in all patients presenting with unexplained collapse, hypotension, vomiting, or diarrhea. The diagnostic test for primary PAI should be paired measurement of serum cortisol and plasma ACTH, and in equivocal cases, a synacthen (tetracosactide) stimulated peak serum cortisol <500 nmol L1 is diagnostic of PAI.

Treatment and Management

Treatment of suspected acute adrenal insufficiency should never be delayed by diagnostic procedures 1. The HPI template should guide appropriate diagnostic testing and management, including morning cortisol levels, ACTH stimulation tests, and imaging studies as indicated to confirm the diagnosis of adrenal insufficiency.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. Patients should be continually monitored for signs that indicate dosage adjustment is necessary, such as remission or exacerbations of the disease and stress (surgery, infection, trauma) In Addison’s disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects. The usual dose is 0.1 mg of fludrocortisone acetate tablets daily, although dosage ranging from 0.1 mg three times a week to 0. 2 mg daily has been employed.

To create an HPI (History of Present Illness) template for suspected adrenal insufficiency, consider the following key points:

• Chief Complaint: Patient's main symptom, such as fatigue, weight loss, or dizziness
• History of Present Illness:
  • Onset and duration of symptoms
  • Severity of symptoms
  • Associated symptoms (e.g., nausea, vomiting, abdominal pain)
  • Triggers or exacerbating factors (e.g., stress, infection, trauma)
  • Response to previous treatments or medications
• Past Medical History:
  • Previous adrenal insufficiency or steroid use
  • Other medical conditions (e.g., diabetes, hypertension)
  • Surgical history
• Medications:
  • Current medications, including steroids
  • Dosage and duration of steroid use
• Social History:
  • Stressors or recent life changes
  • Substance use or abuse
• Review of Systems:
  • Constitutional symptoms (e.g., fever, weight loss)
  • Cardiovascular symptoms (e.g., orthostatic hypotension)
  • Gastrointestinal symptoms (e.g., nausea, vomiting)
  • Musculoskeletal symptoms (e.g., muscle weakness)
  • Neurological symptoms (e.g., confusion, altered mental status)

This template should be used as a guide to gather relevant information for patients with suspected adrenal insufficiency, and the information gathered should be used to inform diagnosis and treatment decisions 2.

From the Research

HPI Template for Suspected Adrenal Insufficiency

The following template can be used to gather information for patients with suspected adrenal insufficiency:

• Chief complaint:
  • Description of the patient's main symptom(s)
  • Duration of the symptom(s)
  • Any factors that exacerbate or relieve the symptom(s)
• History of present illness:
  • Onset and progression of symptoms
  • Associated symptoms such as fatigue, weight loss, or changes in blood pressure
  • Any recent illnesses, surgeries, or stressful events
• Past medical history:
  • Previous diagnoses of adrenal insufficiency or other endocrine disorders
  • History of autoimmune disorders or pituitary tumors
  • Any previous surgeries or treatments that may affect adrenal function
• Medications:
  • Current medications, including glucocorticoids and mineralocorticoids
  • Dosages and frequencies of medications
  • Any changes to medications in the recent past
• Review of systems:
  • General: weight loss, fatigue, or changes in appetite
  • Cardiovascular: changes in blood pressure or heart rate
  • Endocrine: changes in menstrual cycle or sexual function
  • Musculoskeletal: muscle weakness or changes in bone density
• Social history:
  • Occupation and any potential sources of stress
  • Lifestyle habits, including diet and exercise
  • Any history of substance abuse or smoking
• Family history:
  • History of adrenal insufficiency or other endocrine disorders in family members
  • Any genetic disorders that may affect adrenal function

Key Findings and Recommendations

Based on the studies 3, 4, 5, 6, 7, the following key findings and recommendations can be made:

• Adrenal insufficiency is a rare but serious disorder that requires prompt diagnosis and treatment.
• Glucocorticoids and mineralocorticoids are the main therapeutic approaches for adrenal insufficiency.
• Patients with primary adrenal insufficiency generally require mineralocorticoid replacement with fludrocortisone.
• Dehydroepiandrosterone (DHEA) may improve quality of life and mood in patients with adrenal insufficiency, but its use is not yet widely accepted.
• Patients with adrenal insufficiency are at risk of adrenal crisis, which can be prevented with careful education and dose adjustments during stressful events.
• The role of fludrocortisone in cognition and mood is an area of ongoing research, with some studies suggesting that it may improve verbal memory and mood in patients with primary adrenal insufficiency 7.